MEDICARE: LILLY LANDIKUSIC LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	326490-3902	UT

General Provider Information

NPI Number	:	1902084411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILLY LANDIKUSIC LMFT

Provider Business Mailing Address
First Line	:	PO BOX 12842
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84412-2842
Country	:	US
Telephone Number	:	801-695-1316
Fax Number	:

Provider Business Practice Location Address
First Line	:	75 E FORT UNION BLVD STE 135
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-1531
Country	:	US
Telephone Number	:	801-603-2547
Fax Number	:	801-649-0964

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2008
Last Update Date	:	11/16/2023

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